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Rocky Mountain Health Plans - PRIME - Glossary
Unintentional internal or external injuries, examples of accidental injuries are strains, animal bites, burns, contusions, and abrasions (cuts) that result in trauma to the body. Accidental injuries are different from illness-related conditions (being sick) and do not include disease or infection.
Short-term medical treatment provided under the direction of a physician, usually in an acute care hospital for members having an acute illness or injury.
The period of time between the date a patient enters a facility as an inpatient and the date he or she is discharged as an inpatient.
A decision about your health care that you make ahead of time in case you are ever unable to speak for yourself. This will let your family and your doctors know what decisions you would make if you were able to.
Includes any of the following: The denial or limited authorization of a requested service, including determinations based on the type or level of service, requirements for medical necessity, appropriateness, setting or effectiveness of a covered benefit.
- The reduction, suspension or termination of a previously authorized service
- The denial, in whole or in part, of payment for a service
- The failure to provide services in a timely manner (as determined by the State)
- The failure of RMHP to act within the timeframe required for the standard resolution of grievances and appeals
- For a resident in a rural area with only one health plan, the denial of an enrollee’s request to exercise his or her right to obtain services outside the network
- The denial of an enrollee's request to dispute financial liability, including cost sharing, copayments, premiums, deductibles, coinsurance, and other enrollee financial liabilities
Office services requested after a provider's normal or published office hours or services requested on weekends and holidays.
A specially designed and equipped vehicle used only for transporting the sick and injured. It must have customary safety and lifesaving equipment such as first aid supplies and oxygen equipment. The vehicle must be operated by trained personnel and licensed as an ambulance.
Services and supplies (in addition to room expenses) that hospitals and other facilities bill for. Such services include, but are not limited to, the following:
- Use of an operating room, recovery room, emergency room, treatment rooms, and related equipment; intensive and coronary care units
- Drugs/medication and medicines, biologics (medicines made from living organisms and their products) and pharmaceuticals
- Medical supplies (dressings and supplies, sterile trays, casts, and splints used instead of a cast)
- Durable medical equipment owned by the facility and used during a covered admission
- Diagnostic and therapeutic services
- Blood processing and transportation and blood handling costs and administration
- Anesthesia — There are two different types of anesthesia:
- General anesthesia, also known as total body anesthesia, causes the patient to become unconscious or put to sleep for a period of time
- Regional or local anesthesia causes loss of feeling or numbness in a specific area without causing loss of consciousness and is usually injected with a local anesthetic drug such as Lidocaine. Anesthesia must be administered by a provider or certified registered nurse anesthetist (CRNA).
A formal request to review an action when you are not satisfied with a decision made by your health plan.
The testing for hearing disorders through identification and evaluation of hearing loss.
An O.K. or approval for a service.
The dollar amount a provider bills for services or supplies before any applicable in-network provider discounts or adjustments.
A period of a year that begins January 1st and ends on December 31st.
The process that assists enrollees to access necessary covered services that are identified in the care plan. It also provides referral and coordination of other services to support your care plan.
Care manager/case manager
A professional (for example, nurse, doctor or social worker) who works with members, providers and RMHP to coordinate services deemed medically necessary for the member.
Dependence on either alcohol and/or other substances; for example, drugs. See also Substance abuse.
Medication therapy administered as treatment for malignant conditions and diseases of certain body systems.
A system of therapy in which disease is considered the result of abnormal function of the nervous system. This method of treatment usually involves manipulation of the spinal column and specific adjustment of body structures.
Ongoing pain that lasts more than six months that is due to non-life threatening causes and has not responded to current available treatment methods. Chronic pain can continue for the remainder of a person's life.
An expression of dissatisfaction received orally or in writing that is of a less serious or formal nature that is resolved within one (1) business day of receipt.
A visit between a provider and a patient to determine what medical examinations or procedures, if any, are appropriate and needed.
Copayments (copays) are a dollar amount that you pay to the doctor at your visit.
Cost-sharing refers to amounts that a member has to pay when services are received. It includes any combination of the following three types of payments: (1) any deductible amount the plan may impose before services are covered; (2) any fixed “copayment” amounts that a plan may require be paid when specific services are received; or (3) any “coinsurance” amount that must be paid as a percentage of the total amount paid for a service.
Services performed for treatment of conditions related to the teeth or structures supporting the teeth.
Acute treatment for withdrawal from the physical effects of alcohol or another substance.
Tests or services ordered by a provider to determine the cause of illness.
The treatment of acute or chronic kidney ailment. During dialysis, impurities are removed from the body with dialysis equipment.
The evaluation of a patient's medical needs and arrangement of appropriate care after discharge from a facility.
Durable Medical Equipment
Certain items your doctor orders for you to use at home. Examples are walkers, wheelchairs, or hospital beds.
Emergency Medical Condition
An emergency means your life could be threatened or you could be hurt permanently (disabled) if you don't get care quickly. If you are pregnant, it could mean harm to the health of you or your unborn baby.
Emergency Medical Transportation
Your condition is such that you are unable to go to the hospital by any other means but by calling 911 for an ambulance.
Those services necessary to treat an emergency medical condition. Emergency medical condition means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent lay person, with an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in: (i) serious jeopardy to the health of the individual or, in the case of a pregnant woman, the health of the woman or her unborn child; (ii) serious impairment to bodily functions; or (iii) serious dysfunction of any bodily organ or part.
Experimental or investigative procedures or services
a. Any drug/medication, biologic, device, diagnostic, product, equipment, procedure, treatment, service or supply used in or directly related to the diagnosis, evaluation or treatment of a disease, injury, illness or other health condition that RMHP determines, in its sole discretion, to be experimental or investigational. RMHP will deem any drug/medication, biologic, device, diagnostic, product, equipment, procedure, treatment, service or supply to be experimental or investigational if it determines that one or more of the following criteria apply when the service is rendered with respect to the use for which benefits are sought.
- The drug/medication, biologic, device, diagnostic, product, equipment, procedure, treatment, service or Is provided pursuant to informed consent documents that describe the drug/medication, biologic, device, diagnostic, product, equipment, procedure, treatment, service or supply as experimental or investigational, or otherwise indicate that the safety, toxicity or efficacy of the drug/medication, biologic, device, diagnostic, product, equipment, procedure, treatment, service or supply is under evaluation
b. Any service not deemed experimental or investigational based on the criteria in subsection (a) may still be deemed to be experimental or investigational by RMHP. In determining if a service is experimental or investigational, RMHP will consider the information described in subsection (c) and assess all of the following:
- Whether the scientific evidence is conclusory concerning the effect of the service on health outcomes
- Whether the evidence demonstrates that the service improves the net health outcomes of the total population for whom the service might be proposed as any established alternatives
- Whether the evidence demonstrates the service has been shown to improve the net health outcomes of the total population for whom the service might be proposed under the usual conditions of medical practice outside clinical investigatory settings
c. The information RMHP considers or evaluates to determine if a drug/medication, biologic, device, diagnostic, product, equipment, procedure, treatment, service or supply is experimental or investigational under subsections (a) and (b) may include one or more items from the following list, which is not all-inclusive:
- Randomized, controlled, clinical trials published in an authoritative, peer-reviewed United States medical or scientific journal
- Evaluations of national medical associations, consensus panels, and other technology evaluation bodies
- Documents issued by and/or filed with the FDA or other federal, state or local agency with the authority to approve, regulate or investigate the use of the drug/medication, biologic, device, diagnostic, product, equipment, procedure, treatment, service or supply
- Documents of an IRB or other similar body performing substantially the same function
- Consent documentation(s) used by the treating providers, other medical professionals or facilities, or by other treating providers, other medical professionals or facilities studying substantially the same drug/medication, biologic, device, diagnostic, product, equipment, procedure, treatment, service or supply
- The written protocol(s) used by the treating providers, other medical professionals or facilities or by other treating providers, other medical professionals or facilities studying substantially the same drug/medication, biologic, device, diagnostic, product, equipment, procedure, treatment, service or supply
- The opinions of consulting providers and other experts in the field
d. RMHP has the sole authority and discretion to identify and weigh all information and determine all questions pertaining to whether a drug/medication, biologic, device, diagnostic, product, equipment, procedure, treatment, service or supply is experimental or investigational.
Explanation of benefits
Also known as an EOB. An EOB is a printed form sent by an insurance company to a member after a claim has been filed and a decision has been made about the claim. The EOB includes such information as the date of service, name of provider, amount covered and patient balance.
An untruthful act (example: if someone other than you uses your member ID card and pretends to be you).
A prescription drug that is approved by the federal government to use in place of a brand name drug. A generic drug has the same ingredients as a brand name drug. It is usually cheaper and works just as well as the brand name drug.
Your statement of dissatisfaction with any part of your care. A grievance can be filed over the phone or in writing, and must be filed directly with your plan.
Habilitation Services and Devices
Services and devices that help you keep, learn, or improve skills and functioning for daily living.
Home health services
This is also called home health care. These are professional nursing services, certified nurse aide services, medical supplies, equipment and appliances suitable for use in the home, and physical therapy, occupational therapy, speech pathology, and audiology services provided by a certified home health agency to eligible members, who are under a plan of care, in their place of residence.
An agency licensed by the Colorado Department of Public Health and Environment to provide hospice care in Colorado. A hospice is a centrally administered program of palliative (care that controls pain and relieves symptoms), supportive and interdisciplinary team services providing physical, psychological, spiritual, and sociological care for terminally ill individuals and their families, within a continuum of inpatient care, home health care and follow-up bereavement services available 24 hours a day, 7 days a week.
Services to provide comfort and support for persons in the last stages of a terminal illness and their families.
A health institution offering facilities, beds, and continuous services 24 hours a day and that meets all licensing and certification requirements of local and state regulatory agencies.
Hospital Outpatient Care
Care or treatment that does not require an overnight stay in a hospital.
The act of placing a person in a hospital as a patient.
An identifcation card that says you are a UnitedHealthcare Community Plan member. You should have this card with you at all times.
Implantable birth control device
Device inserted underneath the skin that prevents pregnancy.
In-network provider or participating provider
A provider that is contracted with RMHP to provide medical services to RAE members.
A patient who is admitted for an overnight or longer stay at a health care facility and is receiving covered services.
Inpatient medical rehabilitation
Care that includes a minimum of three hours of therapy, for example, speech therapy, respiratory therapy, occupational therapy, and/or physical therapy, and often some weekend therapy. Inpatient medical rehabilitation is generally provided in a rehabilitation section of a hospital or at a freestanding facility. Some skilled nursing facilities have rehabilitation beds.
Stands for intra-uterine device, a birth control device inserted into the uterus to prevent pregnancy.
Cone-shaped protrusion of the cornea.
Laboratory and pathology services
Testing procedures required for the diagnosis or treatment of a condition. Generally, these services involve the analysis of a specimen of tissue or other material that has been removed from the body.
Long-term acute care facility
An institution that provides an array of long-term crucial care services to patients with serious illnesses or injuries. Long-term acute care is provided for patients with complex medical needs. These include patients with high risk pulmonary conditions who have ventilator or tracheotomy needs or who are medically unstable, patients with extensive wound care needs or postoperative surgery wound care needs, and patients with low-level, closed-head injuries. Long-term acute care facilities do not provide care for low-intensity patient needs.
Includes medically necessary pregnancy counseling, pregnancy testing, prenatal care, labor and delivery services, as well as care after delivery.
Maximum medical improvement
A determination at RMHP's sole discretion that no further medical care can reasonably be expected to measurably improve a patient’s condition. Maximum medical improvement shall be determined without regard to whether continued care is necessary to prevent deterioration of the condition or is otherwise life sustaining.
Non-surgical health care services provided for the prevention, diagnosis, and treatment of illness, injury, and other general conditions.
Items (except prescription medications) required for the treatment of an illness or injury.
Mental health condition
Non-biologically based mental conditions that have a psychiatric diagnosis or that require specific psychotherapeutic treatment, regardless of the underlying condition (for example, depression secondary to diabetes or primary depression). RMHP defines mental health conditions based on the American Psychiatric Association's guidelines.
Medical nutrition therapy provided by a qualified nutrition professional such as a registered dietitian without training in pediatric nutrition. Medical nutrition therapy includes nutrition assessment, support, and counseling to determine a treatment plan to increase nutritional intake to promote adequate growth, healing and improved health.
The use of educational and rehabilitative techniques to improve a patient's functional ability to live independently. Occupational therapy requires that a properly accredited occupational therapist (OT) or certified occupational therapy assistant (COTA) perform such therapy.
A surgical process that involves the removal of an organ from one person and placement of the organ into another person. Transplant can also mean removal of body substances, such as stem cells or bone marrow, for the purpose of treatment and re-implanting the removed organ or tissue into the same person.
A support or brace for weak or ineffective joints or muscles.
A nonhospitalized patient receiving covered services away from a hospital, such as in a physician's office or the patient’s own home, or in a hospital outpatient or hospital emergency department or surgical center.
Outpatient medical care
Non-surgical services provided in a provider's office, the outpatient department of a hospital or other facility, or the patient's home.
Weight for height at greater than the 95th percentile or Body Mass Index (BMI) greater than the 95th percentile.
Care that controls pain and relieves symptoms, but does not cure.
Providers, hospitals, home health agencies, clinics, and other places that provide your health care services, medical equipment, and long-term services and supports that are contracted with UnitedHealthcare Community Plan. Participating providers are also "in-network providers" or "plan providers."
An establishment licensed to dispense prescription medications and other medications through a licensed pharmacist upon an authorized health care professional’s order. A pharmacy may be an RMHP in-network or an out-of-network provider. An in-network pharmacy is contracted with RMHP to provide covered medications to members under the terms and conditions of the RAE Member Handbook. An out-of-network pharmacy is not contracted with RMHP.
The use of physical agents to treat a disability resulting from disease or injury. Physical agents used include heat, cold, electrical currents, ultrasound, ultraviolet radiation, massage, and therapeutic exercise. A provider or registered physical therapist must perform physical therapy.
A doctor of medicine or osteopathy who is licensed to practice medicine under the laws of the state or jurisdiction where the services are provided.
Care provided to you by an individual licensed under state law to practice medicine, surgery, or behavioral health.
A benefit, like Medicaid, which provides and pays for your health-care services.
A decision by your health insurer or plan that a health-care service, treatment plan, prescription drug, or durable medical equipment that you or your provider has requested, is medically necessary. This decision or approval, sometimes called prior authorization, prior approval, or pre-certification, must be obtained prior to receiving the requested service. Pre-authorization isn’t a promise your health insurance or plan will cover the cost.
Preferred Drug List (PDL)
A list of approved prescription drugs approved by the Indiana Family Social Services Administration.
Prescription Drug Coverage
Prescription drugs or medications covered (paid) by your UnitedHealthcare Community Plan. Some over-the -counter medications are covered.
Prescription drugs: A drug or medication that, by law, can be obtained only by means of a physician's prescription.
Comprehensive care that emphasizes prevention, early detection and early treatment of conditions through routine physical exams, immunizations, and health education.
Primary Care Provider (PCP)
The doctor who treats you for all normal health care needs. Your PCP may refer you to a specialist or admit you to a hospital. PCPs are usually family practitioners, internists, pediatricians, and sometimes nurse practitioners and physician's assistants, and can include Obstetricians and certified nurse midwives for pregnant members.
A person or facility that provides health care services and treatment such as a doctor, pharmacy, dentist, clinic or hospital.
Quality of Care
Quality of Care (QOC) means the degree to which health services for enrollees/ members increase the likelihood of desired health outcomes and are consistent with current professional knowledge.
X-ray, radon, cobalt, betatron, telocobalt, radioactive isotope, and similar treatments for malignant diseases and other medical conditions.
RAE Member Handbook
Published by Health First Colorado, the RAE Member Handbook explains the benefits, limitations, exclusions, terms, and conditions of a RAE member's health coverage.
Surgery that restores or improves bodily function to the level experienced before the event that necessitated the surgery or in the case of a congenital defect, to a level considered normal. Reconstructive surgery may have a coincidental cosmetic effect.
Periodic review of your family’s income and eligibility. During redetermination, also known as renewal, you must submit proof of current income and residency to verify your eligibility.
Services for conditions not requiring immediate attention and that can usually be received in the PCP's office, or services that are usually done periodically within a specific time frame (for example, immunizations and physical exams).
Second Medical Opinion
A review of a medical condition that is done by another doctor.
The geographic area served by a health plan that provides coverage for Apple Health (Medicaid).
Skilled nursing care facility
An institution that provides skilled nursing care (for example, therapies and protective supervision) for patients with uncontrolled, unstable or chronic conditions.
Skilled nursing care is provided under medical supervision to carry out non-surgical treatment of chronic diseases or convalescent stages of acute diseases or injuries. Skilled nursing facilities do not provide care for patients with high intensity medical needs, or for patients who are medically unstable.
A need that is best addressed by resources out in the community. Your Member Services Advocate can help you access services that will address your social needs.
Special care units
Special areas of a hospital with highly skilled personnel and special equipment to provide acute care, with constant treatment and observation.
Any doctor who has special training for a specific condition or illness.
Speech therapy (also called speech pathology)
Services used for the diagnosis and treatment of speech and language disorders. A licensed and accredited speech/language pathologist must perform speech therapy.
The use of alcohol and/or other substances that leads to negative effects on a person’s physical or mental health.
Substance abuse treatment center
A detoxification and/or rehabilitation facility licensed by the state to treat alcoholism and/or drug abuse.
Any variety of technical procedures for treatment or diagnosis of anatomical disease or injury, including but not limited to, cutting, microsurgery (use of scopes), laser procedures, grafting, suturing, castings, treatment of fractures and dislocations, electrical, chemical or medical destruction of tissue, endoscopic examinations, anesthetic epidural procedures, and other invasive procedures. Covered surgical services also include usual and related anesthesia and pre- and post-operative care, including recasting.
When you are sick but it is not an emergency, and you need treatment or medical advice within a 48-hour time period.
Urgent Care Centers
You can use these centers when it's not a life-threatening situation, but you are sick or need medical care right away and your PCP is not available. Urgent care centers are usually open in the evenings and on weekends.
Utilization Management (UM) Decision
UnitedHealthcare Community Plan decisions made against set criteria.
Virtual visits connect you with a live doctor through a smart phone or computer for non-emergent visits.
Rocky Mountain Health Plans PRIME